Spell of Illness

10.3 - Spell of Illness (Rev. 1, 10-01-03) A3-3622 The A/B MAC (A) or (HHH) makes spell of illness determinations in accordance with the Medicare Benefit Policy Manual, Chapter 3, and these special instructions. A. - Beginning a Spell of Illness in Nonparticipating Provider The noncovered services furnished by a nonparticipating provider can begin a spell of illness only if the provider is a qualified provider. A qualified provider is a hospital (including a psychiatric hospital) or an SNF that meets all requirements in the definition of such an institution even though it may not be participating. It is most unlikely that a nonparticipating hospital that is not accredited by JCAHO or a nonparticipating SNF satisfies the conditions of participation, particularly with regard to utilization review. Therefore, for spell of illness purposes, the A/B MAC (A) or (HHH) assumes that nonparticipating providers are not qualified providers in the absence of evidence to the contrary. Situations that might constitute such contrary evidence include cases where the provider recently dropped out of the program or, after a survey by the State agency, decided not to participate even though the conditions of participation were met. Hospitals accredited by JCAHO are deemed to meet all requirements except utilization review. For such a hospital, the A/B MAC (A) determines through the RO whether the hospital has a utilization review plan in effect. B. - Continuing a Spell of Illness 1. Hospital Services For purposes of continuing a spell of illness in a hospital, the hospital in which the stay occurs need not meet all requirements that are necessary for starting a spell of illness. If there has been a stay in a hospital that might continue the spell of illness and the A/B MAC (A) cannot ascertain its status, the A/B MAC (A) contacts the RO, which maintains a list of all medical facilities and their status. 2. SNF Services For purposes of continuing a spell of illness in a SNF the spell of illness ends when the beneficiary no longer needs or receives a Medicare covered level of care. The A/B MAC (A) uses the following seven presumptions to determine whether the skilled level of care standards were met during a prior SNF stay. If the information upon which to base a presumption is not readily available, the A/B MAC (A) may, at its discretion, review the beneficiary's medical records to determine whether the beneficiary was an inpatient of an SNF for purposes of ending a spell of illness. These special rules for determining whether a beneficiary in a SNF is an inpatient for benefit period purposes is applicable in all cases where a prior SNF stay affects benefit period status, not only when a beneficiary is seeking to continue a benefit period, but also where it results in the beneficiary starting a new benefit period. If the applicable skilled level of care standards were met during a prior SNF stay, the spell of illness is continued with current utilization available to the beneficiary. If the applicable skilled level of care standards were not met during a prior SNF stay, the spell of illness is not continued. A new spell of illness restores full utilization and imposes a cash deductible. Presumptions: Presumption 1: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim was paid for the care, unless such payment was made under limitation of liability rules. Presumption 2: A beneficiary's care in a SNF met the skilled level of care standards if a SNF claim was paid for the services provided in the SNF under the special Medicare limitation on liability rules pursuant to placement in a noncertified bed. See Chapter 30. Presumption 3: A beneficiary's care in a SNF did not meet the skilled level of care standards if a claim was paid for the services provided in the SNF pursuant to the general Medicare limitation on liability rules in Chapter 30. (This presumption does not apply to placement in a noncertified bed. For claims paid under these special provisions, see Presumption 2.) Presumption 4: A beneficiary's care in a Medicaid nursing facility (NF) did not meet the skilled level of care standards if a Medicaid claim for the services provided in the NF was denied on the grounds that the services received were not at the NF level of care (even if paid under applicable Medicaid administratively necessary days provisions which result in payment for care not meeting the NF level of care requirements). Presumption 5: A beneficiary's care in an SNF met the skilled level of care standards if a Medicare SNF claim for the services provided in the SNF was denied on grounds other than that the services were not at the skilled level of care. Presumption 6: A beneficiary's care in an SNF did not meet the skilled level of care standards if a Medicare claim for the services provided in the SNF was denied on the grounds that the services were not at the skilled level of care and no limitation of liability payment was made. Presumption 7: A beneficiary's care in a SNF did not meet the skilled level of care standards if no Medicare or Medicaid claim was submitted by the SNF. Rebuttal of Presumptions Presumptions 1 through 4 cannot be rebutted. Thus, prior Medicare and Medicaid claim determinations that necessarily required a level of care determination for the time period under consideration are binding for purposes of a later benefit period calculation. Although Presumptions 1 through 4 are not in themselves rebuttable, a beneficiary may seek to reverse a benefit period determination that was dictated by one of these presumptions by timely appealing the prior Medicare or Medicaid claim determination which triggered the presumption. Presumptions 5 through 7 can be rebutted by beneficiary showings that the level of care needed or received is other than that which the presumption dictates. Rebuttal showings are permitted at both A/B MAC (A) determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the status of a prior SNF stay is made at the time that an inpatient claim is submitted and/or at the reconsideration level). Evaluate rebuttal documentation even if the presumption being rebutted was triggered by a Medicaid denial. Decisions under presumptions 5 through 7 require the A/B MAC (A) to send a notice to advise the beneficiary of the basis for the determination and the right to present evidence to rebut the determination on reconsideration. Presumption 6 can be rebutted because the Medicare skilled level of care definition for coverage purposes is broader than the skilled level of care definition used here for benefit period determinations. For example, prior hospital care related to the SNF care is included in the Medicare SNF coverage requirements but is not included in the standard for benefit period determinations. Therefore, Medicare payment could have been denied for an SNF stay because of noncompliance with that requirement, even though skilled level of care requirements for benefit period determinations were in fact met by the SNF stay. Consequently, when Medicare SNF payment is denied, the beneficiary must be given the opportunity to demonstrate that he/she still needed and received a skilled level of care for purposes of benefit period determinations to extend a benefit period if this would be to the beneficiary's advantage. NOTE: Effective October 1, 1990, the levels of care that were previously covered separately under the Medicaid SNF and intermediate care facility (ICF) benefits are combined in a single Medicaid nursing facility (NF) benefit. Thus, the Medicaid NF benefit includes essentially the same type of skilled care covered by Medicare's SNF benefit, but it includes less intensive care as well. This means that when a person is found not to require at least a Medicaid NF level of care (as under Presumption 4), it can be presumed that he or she also does not meet the Medicare skilled level of care standards. However, since the NF benefit can include care that is less intensive than Medicare SNF care, merely establishing that a person does require NF level care does not necessarily mean that he or she also meets the Medicare skilled level of care standards. Determining whether an individual who requires NF level care also meets the Medicare skilled level of care standards requires an actual examination of the medical evidence and cannot be accomplished through the simple use of a presumption. Medicare no payment bills submitted by an SNF result in Medicare program payment determinations (i.e., denials). Therefore, such no payment bills trigger the appropriate presumptions. This also applies in any State where the Medicaid program utilizes no payment bills which lead to Medicaid program payment determinations. If an SNF erroneously fails to submit a Medicare claim (albeit a no-pay claim) when Medicare rules require such submission, request compliance. Once the no-pay bill is submitted and denied, the applicable presumption (other than presumption 7) is triggered. If a patient is moving from a SNF level of care to a non-SNF level of care in a facility certified to provide SNF care, occurrence code 22 (date active care ended) is used to signify the beginning of the no- pay period on the bill and trigger the appropriate presumptions. Some of the presumptions require knowledge of Medicaid's claims processing involvement with the prior claim. The A/B MAC (A) uses current bill data, accompanying documentation, bill history files, and telephone contacts with the prior stay facility and/or the Medicaid agency to develop the Medicaid aspects. It does not continue Medicaid development beyond a telephone contact. It concludes its consideration of the presumption at this point based upon the Medicaid information available.